EXECUTIVE SUMMARY

Results from a new study identify mental health conditions associated with an increased risk of unnecessary bilateral oophorectomies, despite nonmalignant indications. Related research indicates that hysterectomy is associated with an increased risk of long-term mental health issues, including depression and anxiety.

• Hysterectomy is performed not only for malignant disease but also for many benign conditions, such as fibroids, endometrial hyperplasia, adenomyosis, uterine prolapse, dysfunctional uterine bleeding, and cervical intraepithelial neoplasia.

• Alternatives to hysterectomy include laparoscopic adenomyomectomy in the case of focal adenomyosis, uterine artery embolism for treatment of uterine fibroids, and thermal uterine balloon therapy system for endometrial ablation.


Results from a new study identify mental health conditions associated with an increased risk of unnecessary bilateral oophorectomies, despite nonmalignant indications.1 In related research, findings indicate that hysterectomy is associated with an increased risk of long-term mental health issues, including depression and anxiety.2

Both analyses were conducted by scientists at the Mayo Clinic using data collected from the Rochester Epidemiology Project, a collaboration of clinics, hospitals, and other medical facilities in Minnesota and Wisconsin that share their medical records for research.

In the first study, researchers examined whether various psychiatric symptoms influence a woman’s decision to undergo an oophorectomy, even if there was no threat of malignancy. The study included 2,000 women, each of whom was age-matched to a referent woman residing in the same county who had not undergone hysterectomy or oophorectomy before the index date. Researchers identified several psychiatric conditions associated with an increased risk of undergoing surgery, including mood disorders, bipolar disorders, anxiety disorders, schizophrenia, personality disorders, dissociative disorders, and somatoform disorders.1

While previous investigations have studied the effects of hysterectomy with or without concurrent bilateral oophorectomy on mental health outcomes, this new study is the first to identify psychiatric conditions before a bilateral oophorectomy.

“This study serves as an important reminder that mental health issues are common and can sometimes present with physical symptoms,” Stephanie Faubion, MD, MBA, FACP, NCMP, medical director of the North American Menopause Society, said in a statement. “It is incumbent on primary care providers, including gynecologists, to determine whether mental health conditions are playing a role in gynecologic complaints in order to provide patients with the most appropriate care.” (Faubion’s comments can be found at: https://bit.ly/2lCn10i.)

There are significant, long-term, adverse health consequences associated with removing a woman’s ovaries before the natural age of menopause in addition to the potential risks of an unnecessary surgical procedure, Faubion commented.

Procedure Leaves Lasting Effect

In the second analysis, which involved 2,100 women, researchers examined health records from 1980 to 2002, studying women who underwent removal of the uterus. Researchers looked for new diagnoses of depression, anxiety, dementia, substance abuse, and schizophrenia after hysterectomy, and excluded women with prior diagnoses.

The data showed an absolute risk increase of 6.6% for depression and 4.7% for anxiety over 30 years. For women who underwent hysterectomy between the ages of 18-35 years, the risk of depression was higher, with an absolute risk increase over 30 years of 12%.2

“Our study shows that removing the uterus may have more effect on physical and mental health than previously thought,” says lead author Shannon Laughlin-Tommaso, MD, a Mayo Clinic obstetrician/gynecologist. “Because women often get a hysterectomy at a young age, knowing the risks associated with the procedure even years later is important.” (Read Laughlin-Tommaso’s remarks at: https://mayocl.in/2lz5JSs.)

Hysterectomy is performed for malignant disease and many benign conditions, such as fibroids, endometrial hyperplasia, adenomyosis, uterine prolapse, dysfunctional uterine bleeding, and cervical intraepithelial neoplasia. Procedures include abdominal hysterectomy, vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy, total laparoscopic hysterectomy, and subtotal laparoscopic hysterectomy, where there is no vaginal component and the uterine body is removed using a morcellator.3

Alternatives to hysterectomy include laparoscopic adenomyomectomy in the case of focal adenomyosis, uterine artery embolism for treatment of uterine fibroids, hysteroscopic cautery to the endometrium with resectoscope, and thermal uterine balloon therapy system for endometrial ablation.3 If bleeding management is the goal, options such as pills, the levonorgestrel intrauterine device, contraceptive patch, or ring are options.

Hysterectomy once was the only widely available option for women with uterine fibroids. But new procedures are available, and clinicians need to understand the pros and cons of each. A session at the 2018 annual meeting of the American College of Obstetricians and Gynecologists focused on the surgical and nonsurgical options for women.

“If you look at the data across the United States, 75% of fibroid surgeries are hysterectomies,” said Elizabeth Stewart, MD, professor of obstetrics and gynecology and chair of the Division of Reproductive Endocrinology and Infertility at Mayo Clinic, who presented on surgical treatment options. “While there’s a place for hysterectomy, there are still many more women that can have an effective surgical alternative to hysterectomy.”

REFERENCES

  1. Gazzuola Rocca L, Smith CY, Bobo WV, et al. Mental health conditions diagnosed before bilateral oophorectomy: A population-based case-control study. Menopause 2019; doi: 10.1097/GME.0000000000001413.
  2. Laughlin-Tommaso SK, Satish A, Khan Z, et al. Long-term risk of de novo mental health conditions after hysterectomy with ovarian conservation: A cohort study. Menopause 2019;doi: 10.1097/GME.0000000000001415.
  3. Papadopoulos MS, Tolikas AC, Miliaras DE. Hysterectomy-current methods and alternatives for benign indications. Obstet Gynecol Int 2010;doi:10.1155/2010/356740.